[Giant traumatic diaphragmatic hernia as a complication after laparoscopic liver surgery]. / Gigantskaya travmaticheskaya diafragmal'naya gryzha kak oslozhnenie posle laparoskopicheskoi operatsii na pecheni.

Laparoscopic surgery is now one of the main options for patients with surgical diseases of abdominal cavity, pelvis and retroperitoneal space. Postoperative complications are known, and methods for their prevention after such interventions are well developed. However, there are rare complications, and their management deserves a special attention. The authors present a patient with giant traumatic hernia in long-term period after laparoscopic liver surgery. Clinical manifestations of disease are retrospectively analyzed. The authors discuss surgical aspects of treatment, i.e. choice of access, repair of diaphragmatic defect and peculiarities of postoperative period associated with non-anatomic return of abdominal organs through the diaphragmatic defect. This report will be useful for radiologists, thoracic and abdominal surgeons, anesthesiologists and intensive care specialists.

Traumatic Diaphragmatic Lesions - Considerations Over a Series of 15 Consecutive Cases.

Introduction: Diaphragmatic injuries are produced by blunt or penetrating thoracoabdominal trauma. They are potentially life-threatening due to the herniation of abdominal organs into the pleural cavities and severe associated lesions. The aim of this retrospective study was to analyse the clinical presentation and management of patients admitted with diaphragmatic rupture in our institution. Material and Method: We performed a 5-year retrospective study of patients admitted with acute blunt or penetrating diaphragmatic rupture in the Department of General Surgery of "Bagdasar- Arseni" Emergency Hospital. We have studied sex, age, mechanism of trauma, side-location, timeto-diagnosis, concomitant injuries, surgical treatment and outcome. Results: Fifteen patients (8 males, 7 females, mean age: 42 years) with diaphragmatic rupture (left-side: 13, right-side: 2) following blunt (8 patients) or penetrating (7) trauma were included. Patients with blunt diaphragmatic injury had larger tears and abdominal viscera herniation was observed in 6of these cases. A direct suture was performed for all 15 patients. Laparotomy was the surgical approach preferred in most of the cases. Mortality rate was 20%, mainly caused by severe associated lesions. Conclusion: Although traumatic diaphragmatic lesions are frequently associated with severe cerebral and thoraco-abdominal trauma that is also the main cause of death, a prompt diagnosis and treatment can lead to good outcome.

[Giant posttraumatic diaphragmatic hernia in 17 years after rupture of the diaphragm]. / Lechenie gigantskoi posttravmaticheskoi diafragmal'noi gryzhi cherez 17 let posle razryva grudobriushnoi pregrady.

Blunt chest trauma followed by diaphragm rupture is a severe injury requiring surgical correction both in acute and long-term periods. Posttraumatic diaphragmatic hernia is dangerous by infringement of dislocated organs. Thanks to adaptive mechanisms of the organism, patients with non-functioning half of the diaphragm have a good quality of life for a long time. Symptoms (respiratory disorders and arrhythmia, predominantly) occur over time in patients with concomitant diseases and impaired function of vital organs. At the same time, simultaneous thoracic and abdominal surgery is possible. Thoracotomy is advisable for injury of the right half of the diaphragm, thoracotomy and laparotomy - for injury of the left half. It is presented case report of diaphragm repair by primary suture without application of strengthening materials in 17 years after complex trauma. In this case, diaphragm function was restored that resulted improved quality of life.

A case of diaphragmatic hernia following colonoscopy.

An 89-year-old woman with a history of traumatic injury was referred to our hospital for further evaluation of anemia. Two days after colonoscopy, she complained of intermittent abdominal pain. An abdominal computed tomography confirmed a left diaphragmatic defect with a herniated transverse colon. She underwent elective laparoscopic repair of the diaphragmatic hernia. Colonoscopy rarely causes or worsens a diaphragmatic hernia. This is a rare case where we observed the development and exacerbation of a diaphragmatic hernia. It is important to pay attention to the development of a diaphragmatic hernia after colonoscopy for patients with a history of traumatic injury.

Traumatic Diaphragmatic Hernia: Diagnostic Dilemma.

Traumatic rupture of the diaphragm is an uncommon condition. The prevalence of diaphragmatic rupture among blunt trauma victim ranges from 0.8 to 8%. The etiologic factors are blunt trauma (for example, in motor vehicle accidents) and penetrating trauma. The diagnosis is often missed because of non-specific clinical signs, and the absence of additional intra-abdominal and thoracic injuries. We present a case which was misdiagnosed as a case of left sided hemopneumothorax and treated with tube thoracotomy in other center.

Role of thoracoscopy in traumatic diaphragmatic hernia.

Thoraco-abdominal trauma can in rare cases involve diaphragmatic rupture and subsequent herniation of intra-abdominal contents. We report a case of this complication in a 5-year-old boy who was injured in a car crash, and who manifested respiratory distress and hemodynamic instability after 48 h of being monitored in the pediatric intensive care unit. Multiple radiologic investigations were inconclusive and the definite diagnosis was established only on thoracoscopic exploration.

Traumatic Right Diaphragmatic Hernia; A Delayed Presentation.

Diaphragmatic rupture following blunt or penetrating thoraco-abdominal trauma is frequently missed. It presents years later with herniation of abdominal viscera. Surgical treatment should be sought for when diagnosed. A 56 year old female presented to emergency with traumatic right diaphragmatic hernia, road traffic accident 8 years ago when she sustained multiple rib fractures on the right side. Upon diagnosis, successful primary hernia repair was performed. Non-specific clinical and radiological features of diaphragmatic hernia (diminished breath sounds, respiratory distress, orthopnoea, dyspnoea, hydro-pneumothorax, and mediastinal shift and lung collapse) lead to delayed or missed diagnosis. Patients present months to years later with complications. By including it in the differentials while managing a trauma patient along with collaboration of the radiology department, the chances of missing this finding would be lowered substantially.

Imaging of Traumatic Diaphragmatic Rupture: Evaluation of Diagnostic Accuracy at a Level 1 Trauma Centre.

PURPOSE: Traumatic diaphragmatic rupture (TDR) is an uncommon injury that can be associated with significant morbidity if not detected and treated in a timely manner. The purpose of our study was to evaluate the diagnostic accuracy of 64-slice multidetector computed tomography (64-MDCT) for the detection of TDR in patients at our level 1 trauma centre. METHODS: We used our hospital's trauma registry to identify patients with a diagnosis of TDR from January 1, 2008, to December 31, 2012. Only patients with a 64-MDCT scan at presentation who subsequently underwent laparotomy/laparoscopy were included in the study cohort. Using surgical findings as the gold standard, the accuracy of the prospective radiology reports was analyzed. RESULTS: Of the 3225 trauma patients who presented to our institution, 38 (1.2%) had a TDR. Fourteen of the 38 were excluded as they did not have MDCT before surgery. The study cohort consisted of 20 males and 4 females with a median age of 34.5 years and a median Injury Severity Score (ISS90) of 26. Fifteen had blunt trauma while 9 had a penetrating injury. The overall sensitivity of the radiology reports was 66.7% (95% confidence interval [CI]: 46.7%-82.0%), specificity was 100% (95% CI: 94.1%-100%), positive predictive value was 100% (95% CI: 80.6%-100%), negative predictive value was 88.4% (95% CI: 78.8%-94.0%), and accuracy was 90.6% (95% CI: 82.5%-95.2%). However, only 3 of 9 patients with penetrating injury had a correct preoperative diagnosis. Two of the 6 missed penetrating trauma cases had only indirect signs of injury. CONCLUSIONS: The detection of TDR in trauma patients on 64-MDCT can be improved, especially in patients presenting with penetrating injury. A careful search for subtle diaphragmatic defects and indirect evidence of injury is important to avoid missing the diagnosis.

[Bilateral post-traumatic diaphragmatic hernias].

Traumatic diaphragmatic hernias could be clinically apparent and diagnosed after months and years after trauma. Bilateral ruptures of the diaphragm rarely appeared. Patients (46 cases) with diaphragmatic hernias were treated at the period from 1998 to 2010. The rate of diaphragmatic hernias consisted of 41,3%, bilateral post-traumatic hernias was noted in 2.2%. The article presents a follow-up study of bilateral diaphragmatic hernia, which was formed on the left (after 1 year) and on the right after 5 years. Diagnosis was supported by radiographic contrast research and computed tomography data. The stomach and omentum were displaced to the pleural cavity on the left, the transversely colon and omentum had a shift on the right. Thoracotomy and diaphragm plasty were performed in both cases. Hernial orifice was located in the area of esophageal opening and crura of diaphragm. It is necessary to increase clinical suspicion in relation to possibility of diaphragmatic hernia origin after severe closed trauma.

Asymptomatic traumatic diaphragmatic hernia discovered during an aortic valve replacement.

Asymptomatic traumatic diaphragmatic hernia, which presents in an adult, is an extremely rare entity. We discuss the management of a 63-year-old male with an asymptomatic traumatic diaphragmatic hernia discovered during aortic valve replacement.

Missed diagnosis of a delayed diaphragmatic hernia as intestinal obstruction: a case report.

Penetrating diaphragmatic injury rarely occurs in isolation. Diagnosis of traumatic diaphragmatic hernia resulting from penetrating diaphragmatic injury may be delayed or missed with attendant high morbidity and mortality. We reported a 28-year-old man who presented with features of subacute intestinal obstruction which became severe over the last four days. He had a stab injury to his left lower chest wall that was sutured 31/2 years prior to the development of symptoms. Emergency laparotomy with incidental findings of missed diaphragmatic hernia with gangrenous jejunal segment was found. The hernia was reduced, gangrenous segment resected with end to end anastomosis, and repair of diaphragmatic rent done. He had an uneventful recovery and follow up. There is the need to maintain high index of suspicion of Traumatic Diaphragmatic Hernia (TDH) in a patient with recent or previous thoraco-abdominal injury that will reduce the rate of missed or delayed diagnosis.

[Features of diagnostics and surgical strategy of diaphragmatic rupture in patients with closed chest and abdominal polytrauma].

The article presents results of diagnostics and surgical treatment of diaphragmatic rupture in 32 victims with an estimation of diagnostic value of different instrumental methods of investigation and the efficacy of surgical approach. The correct interpretation of typical clinical and instrumental signs in consideration with trauma mechanogenesis allowed diagnostics of diaphragmatic rupture before the operation in 17 (53.1%) cases. It was observed that an undiagnosed rupture of the left hemidiaphragm caused a formation of posttraumatic diaphragmatic hernia in 2 (6.2%) patients. The laparotomy was applied in 28 patients as a surgical approach and thoracotomy--in 2patients. The laparotomy and after that thoracotomy were performed on one patient. The thoracotomy and laparotomy were carried out on the second patient in turn. The authors consider the laparotomy as optimal variant of surgical approach in acute period of trauma. The postoperative lethality was 15.6%.

Management of delayed presentation of a right-side traumatic diaphragmatic rupture.

BACKGROUND: Right-side diaphragmatic rupture is an unusual condition after blunt trauma. The diagnosis may be missed during the early period of trauma and may lead to progressive herniation of intraabdominal contents into the thorax. In this study, we aimed to evaluate the diagnosis and treatment options for the late diagnosis of cases of right-side traumatic diaphragmatic rupture. METHODS: We evaluated the patients with diaphragmatic hernia who were admitted to the hospital during an 8-year period. Only patients with a right-side diaphragmatic hernia and a history of high-energy trauma were included in the study. Patients with left-side diaphragmatic hernia or those who were subjected to emergency operation due to diaphragmatic rupture were excluded from the study. Patient characteristics, clinical presentations, diagnostic tools, and treatment options were evaluated. RESULTS: Eight patients (five men, three women) were enrolled in the study. The most common trauma type was a traffic accident, and the average interval between the trauma and diagnosis was 10 years. Thoracoabdominal computed tomography had high sensitivity and specificity for visualizing the diaphragmatic hernia. No predisposing factor was found to add laparotomy to thoracotomy. There was no postoperative mortality, and no late complications were observed at the assessments during the 45-month follow-up. CONCLUSIONS: Clinical presentation of late diagnosed diaphragmatic hernia, which is encountered only rarely on the right side, requires diagnostic and therapeutic approaches different from those associated with acute diaphragmatic rupture. It should not be forgotten during the differential diagnosis in patients with a history of trauma.

Delayed enterothorax and hepatothorax due to missed right-sided traumatic diaphragmatic rupture.

Traumatic diaphragma ruptures (DRs) are an unusual condition after blunt thoracoabdominal trauma, and there are some difficulties in the diagnosis, in the absence of the additional life-threatening injuries. Right-sided injuries are less frequent than left-sided injuries and may be missed easily. Intrathoracic herniation of abdominal organs is an uncommon condition for right-sided DR. Particularly, to our knowledge, progressive hepatothorax and enterothorax that develop over years are a very rare presentation of DR. Herein, we present a case of progressive thoracic herniation of the abdominal organs, diagnosed 22 years after the initial trauma.

Late gastric incarceration 20 years after penetrating chest trauma.

The diagnosis of diaphragmatic injury in trauma patients is a challenge for surgeons. Misdiagnosis is common and can only be corrected when patients present with symptoms of diaphragmatic hernia. We report a rare case of delayed traumatic diaphragmatic hernia masquerading as empyema 20 years after lower chest penetrating trauma. The herniated stomach was found intraoperatively. Delayed traumatic diaphragmatic hernia should always be suspected in patients with trauma that may have occurred many years ago.

Tension viscerothorax after blunt abdominal trauma: a case report and review of the literature.

BACKGROUND: Tension viscerothorax is herniation of abdominal viscera into the thorax. Tension viscerothorax can simulate tension pneumothorax. Immediate decompression with a nasogastric tube is required for hemodynamic stabilization. OBJECTIVE: A case of tension viscerothorax is reported along with a review of the literature to highlight this rare complication of blunt abdominal trauma, and to emphasize the importance of nasogastric tube decompression in tension viscerothorax. CASE REPORT: A 10-year-old boy with a remote history of trauma related to a motor vehicle crash was brought into the Emergency Department with a 3-day history of vomiting, epigastric pain, and dyspnea. By physical examination and chest X-ray study, tension gastrothorax was diagnosed. Nasogastric tube placement was difficult and delayed, and the patient deteriorated into cardiac arrest, but after successful cardiopulmonary resuscitation and nasogastric tube insertion, the patient was stabilized. Laparotomy was performed and primary repair of a ruptured diaphragm was done. The patient made an uneventful recovery. CONCLUSION: Acute tension viscerothorax should be considered in the differential diagnosis of tension pneumothorax, and its initial resuscitation should include nasogastric tube insertion for immediate decompression.

[Traumatic diaphragmatic hernia].

Historical and statistical data on traumatic diaphragmatic hernias are presented. It was shown that frequency of occurrence of the pathology in question was dependent on principal causes of its development, anatomic features of diaphragmatic hernias and mechanisms of damage of the diaphragm. In the article the author notes that the worsening of criminogenic situation, increased number of road and traffic accidents were principal causes of the development of diaphragmatic hernias. Special place in the review is given to strangulated diaphragmatic hernias. The basic diagnostic methods for this pathology are radiological investigation, computed tomography and ultrasonic scanning. In addition, the methods of treatment, prognosis of the development of diaphragmatic hernias, complications included, are presented.

[Diaphragmatic rupture and right ipsilateral intercostal hernia in chronic cough]. / Rupture diaphragmatique et hernie intercostale droites homolatérales sur toux aiguë.

INTRODUCTION: We are reporting the case of a 64-year-old patient with chronic cough who has been diagnosed with an intercostal hernia with pleural and hepatic content associated with a diaphragmatic hernia of non-traumatic origin. CASE REPORT: The patient was treated for an acutely febrile cough with signs of respiratory distress. Thoracic scan showed an intercostal hernia containing an encysted hematoma and a right anterior diaphragmatic hernia with epiploic content. The COVID PCR was negative. This is one of the rare reported cases of intercostal hernia associated with a homolateral diaphragmatic rupture. Visceral and thoracic surgery enabled treatment of the two hernial orifices by raphy as well as omentectomy of the necrotic omentum ascending to the right pulmonary hilum. CONCLUSION: These two parietal complications of chronic cough should be considered in case of intercostal flap or acute respiratory distress. Surgery must then be carried out as a matter of urgency to reduce the content of the hernias and treat the musculoaponeurotic dehiscent orifices.

Diaphragmatic hernia during pregnancy: a case report with a review of the literature from the past 50 years.

Diaphragmatic hernia is a rare complication during pregnancy. Only 30 reports have been published on this subject in English between 1959 and 2009. Due to misdiagnoses and management delays, diaphragmatic hernia usually presents itself as a life-threatening emergency. Here, we present a case report of a patient with a traumatic diaphragmatic hernia who became acutely symptomatic during pregnancy. The diaphragmatic hernia was managed successfully, and we describe the presentation, management and outcome of this case. We also present a review of all of the reported cases of diaphragmatic hernias complicating pregnancy that have been published in English during the past 50 years.

Delayed presentation of posttraumatic diaphragmatic hernia.

BACKGROUND: Missed diaphragmatic injuries after trauma may present with herniation of intraabdominal organs into the thoracic cavity. We aimed to review our patients who presented with delayed posttraumatic diaphragmatic hernia. METHODS: A retrospective review of the medical records of patients with delayed diagnosis of posttraumatic diaphragmatic hernia between 2001 and 2009 was performed. RESULTS: Ten patients with a mean age of 44.3 years were included. Six patients were female. Blunt injuries (n: 7) were more common. Mean duration between trauma and presentation to the hospital was 5.9 years (4 months - 19 years). Nine patients had left-sided diaphragmatic hernia. All patients had chest X-ray and most were diagnostic (n: 8). Additional diagnostic imaging with computerized tomography (CT) and magnetic resonance (MR) was used in seven patients. For the repair, laparotomy incision was chosen for seven patients and thoracotomy incision for two patients. One patient underwent left thoracoabdominal approach. Mesh repair was used in seven patients. Postoperative mean hospitalization was 10.6 days. Empyema and atelectasis were the morbidities in one patient. No postoperative mortality was detected. CONCLUSION: Delayed presentation of posttraumatic diaphragmatic hernia is a serious challenge for trauma surgeons. Prompt diagnosis and treatment prevent serious morbidity and mortality associated with complications such as gangrene and/or perforation of the herniated organ.